The four quadrant approach
Jonsen, Siegler and Winslade; Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (3rd edition McGraw-Hill 1992)
The following questions should be worked through in order.
Indications for medical intervention - establish a diagnosis, what are the options for treatment, what are the prognoses for each of the options.
Preferences of patient - is the patient competent- if so what does he / she want? If not competent then what is in the patient’s best interest?
Quality of life - will the proposed treatment improve the patient’s quality of life?
Contextual features - do religious, cultural, legal factors have an impact on the decision?
Consideration of the ethical issues in a case using the four quadrant approach
Mrs Y is 56 years old and has a learning disability. She is admitted to hospital with an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has indicated quite clearly that she does not want a needle inserted for the anaesthetic for the operation to remove the cyst- she is uncomfortable in a hospital setting and is frightened of needles.
The clinician is concerned that if the cyst is not removed Mrs Y will develop renal failure and require dialysis which would involve the regular use of needles and be very difficult to carry out given her fear of needles and discomfort with hospitals. The anaesthetist is concerned that if Mrs Y does not comply with the procedure then she would need to be physically restrained. Mrs Y’s niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment.
Should the surgeon perform the operation despite Mrs Y’s objections?
Mrs Y has been diagnosed with an ovarian cyst and so the options for treatment should be considered. What is the prognosis with the operation, considered against the prognosis without treatment (or with ongoing dialysis)? If she does not have the operation and requires dialysis, is this going to be manageable; will she be able to get to hospital many times a week and will this interfere with work or caring commitments she may have?
Mrs Y has a learning disability. This does not mean that she is automatically incompetent to make a decision about her treatment. Her competence would need to be assessed using the Re C test (see Consent and Refusal pages). If she is incompetent (and this is not temporary incompetence) then the decision about treatment should be taken in her best interests. It is in her medical best interests to have the operation but it is not in her interests to forcibly restrain her in order to carry out the treatment. These benefits and disadvantages need to be balanced to arrive at a decision about which course of treatment to follow.
Quality of Life:
Will the operation improve the Mrs Y’s quality of life? It is a one –off treatment that, if all goes to plan, will return her to her previous standard of health.
Are there any religious or cultural factors here that may be relevant? What care will she receive after the operation? To what extent will Mrs Y’s niece continue to provide support? It would be useful to know if there is any particular reason why Mrs Y is so frightened of needles and why she feels uncomfortable in hospitals?